Provider Demographics
NPI:1053876854
Name:MOODY, BRANDON JAMES I
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:JAMES
Last Name:MOODY
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5333 MAIN ST APT 104
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2142
Mailing Address - Country:US
Mailing Address - Phone:419-708-4547
Mailing Address - Fax:
Practice Address - Street 1:110 S MADISON ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2518
Practice Address - Country:US
Practice Address - Phone:517-265-5161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program